Cervical Stenosis and Cervical Dilation

CHAPTER 136 Cervical Stenosis and Cervical Dilation

Linda Prine

Cervical stenosis is a stricture or narrowing of the cervix. It is diagnosed by the inability to pass a 2-mm dilator into the uterus. Cervical stenosis can be either congenital or acquired. Acquired stenosis can result from postoperative scarring (from conization, whether it be cold knife, large loop electrosurgery, or laser; cautery; or cryotherapy of the cervix), cancer (endometrial or endocervical), radiation complications, infections, or atrophy from lack of estrogen (most common). In acquired cases the external os is most frequently affected (Fig. 136-1). In congenital cases, seen most often in nulliparous cervices, the stenosis is usually at the internal os.

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Figure 136-1 External os stenosis after loop electrosurgical excision procedure.

Narrowing of the cervical canal can impede menstrual flow, causing intrauterine pressure during menses. Premenopausal women with cervical stenosis may have pelvic pain, dysmenorrhea, amenorrhea, infertility, or abnormal bleeding. In some cases retrograde menstrual flow may occur, causing endometriosis. Women may have a soft, slightly tender midpelvic mass as a result of hematometra. Postmenopausal women may have pyometra, which is highly suspect for endometrial carcinoma.

Ultrasonography can assess canal anatomy while evaluating the patient for hematometra and a pyometra. Most often, cervical stenosis is discovered when the physician is attempting to enter the uterus for a Pap smear, hysteroscopy, intrauterine device (IUD) insertion, endometrial biopsy, uterine aspiration for elective or spontaneous abortion, or placement of Essure devices.

Cervical Dilation

Treatment of cervical stenosis consists of dilation by using (1) progressive metal or plastic dilators, (2) osmotic tents, or (3) prostaglandin analogs. Laminaria tents are made from the stems of seaweed, usually Laminaria japonica, that is dried and made into sticks. Self-expanding cervical dilators (Dilateria, Lamicel) that resemble laminaria tents can also be used. Once the tents are placed into the endocervical canal, they rehydrate and expand, thereby causing dilation of the cervical canal (Figs. 136-2 and 136-3). Laminaria tents should not be used if pyometra is present or infection is suspected. The os and canal must be patent enough to admit the tents, which are available in several diameters. Some mechanical dilation may be necessary to allow their placement. Another option for the treatment of external os stenosis is the use of the carbon dioxide laser or a small radiofrequency loop excision. The latter two methods can remove a stricture that is readily visible externally.

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Figure 136-2 A, Laminaria before insertion. B, Swollen laminaria after removal.

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Figure 136-3 Close-up of laminaria in Figure 136-2A.

Recently, clinicians have come to depend on the administration of misoprostol for softening and dilating the cervix. Misoprostol is most effective on the pregnant uterus, and very small doses are used to soften the cervix for labor. Documentation of efficacy is best in the pregnant uterus. In nonpregnant uteri, efficacy has been shown clearly in women of reproductive age. Studies of misoprostol use on postmenopausal women are conflicting regarding its effectiveness. In nonpregnant uteri or in the first trimester, two to four 200-µg tablets administered vaginally, buccally, or sublingually 1 to 2 hours before the procedure is usually effective.

The majority of dilations can be performed in the office. For extremely anxious patients or if pain cannot be controlled easily, the procedure may need to be performed in the operating room.

Indications

• Symptomatic stenosis (e.g., dysmenorrhea)
• Inability to obtain adequate Pap smears
• IUD insertion
• To perform an indicated endocervical curettage or dilation and curettage
• To perform an aspiration abortion
• If needed for hysterosalpingogram
• Before hysteroscopy
• Before endometrial ablation techniques
• To perform an endometrial biopsy
• To insert Essure devices for mechanical tubal occlusion

Contraindications

Absolute

The procedure is absolutely contraindicated in a patient who is trying to become pregnant.

Relative

• Laminaria tents are not to be used in cases of pyometra
• Pelvic inflammatory disease; vaginal or cervical infections (treat before dilation)

Equipment

• Table that allows the patient to be placed in the lithotomy position
• Needle extender or long spinal needle to provide local anesthesia, if needed (see Chapter 149, Loop Electrosurgical Excision Procedure for Treating Cervical Intraepithelial Neoplasia)
• 5 mL 1% lidocaine
• Adequate light source
• Appropriately sized vaginal speculum
• Nonsterile gloves; use sterile gloves if a procedure entering the uterus is to be performed
• Ring forceps
• Uterine sound—plastic, malleable preferred
• Denniston plastic dilators (1 to 8 mm; Fig. 136-4) or metal dilators (1 to 6 mm) and/or osmotic tent (various sizes; see Fig. 136-2)
• OS Finder or os locator or small silver probe (like a tear duct probe)
• Cervical single-tooth tenaculum
• Paracervical block kit with 10 mL 1% lidocaine in a 10-mL syringe with a 6-inch, 20-gauge needle; may be helpful if dilation of more than 4 to 6 mm is done (see Chapter 173, Paracervical Block)
• 4 × 4 gauze; povidone–iodine (Betadine) solution
• Ultrasonography machine with abdominal probe if needed for guidance (optional)
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Figure 136-4 Denniston plastic dilators, 5 mm to 14 mm sizes.

Preprocedure Patient Education

• Obtain informed consent from the patient. (See the patient consent form available online at ww.expertconsult.com.)
• The patient can insert 400 to 800 µg of misoprostol at home before the procedure, or the clinician can insert it at the time of the procedure when the stenosis is discovered.
• Generally 800 mg of ibuprofen 1 hour before the procedure helps with pain management. Consider diazepam 10 mg by mouth for the anxious patient.
• If further sedation is needed, see Chapter 2, Procedural Sedation and Analgesia.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Cervical Stenosis and Cervical Dilation

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